Anemia May Worsen Prognosis of Primary Care Patients with Heart Failure

A new retrospective analysis of the Swedish heart failure registry found anemia in patients with heart failure (HF) managed in primary care was as frequent as in secondary care, and was linked to a higher risk of hospitalization and mortality.¹

This analysis linked data on more than 9000 patients managed in primary care from the national SwedeHF registry, with a multivariate Cox proportional hazards regression analysis performed to model the time to the diagnosis of anemia.

“The finding that anemia was associated with a raised risk of hospitalization and mortality in patients whose HF is managed in primary health care underscores the need to examine these patients for anemia,” wrote the investigative team, led by Professor Per Wändell, department of family medicine and department of neurobiology, care sciences and society, Karolinska Institutet.

With an increasing prevalence of HF globally, many individuals, particularly older populations and women, are often treated in primary care rather than secondary care.² Comorbidities are frequent in patients with HF, increasing morbidity and mortality risk—anemia is a common comorbidity in HF, decreasing quality of life and increasing hospitalization and mortality rates.³

Previous reports have shown patients with concomitant HF and anemia experience a higher risk of all-cause mortality, cardiovascular mortality, and death due to malignancy, compared with those without comorbidity.⁴ In this analysis, Wändell and colleagues sought to evaluate the prevalence, comorbidities, and prognosis of HF patients with anemia in primary care.¹

The team linked data from SwedeHF with other Swedish national register data, identifying 9300 patients with HF managed in primary care between January 2001 and December 2018. To link baseline characteristics with anemia, investigators included 44 clinically relevant baseline characteristics as covariates in a multivariable logistic regression model, with anemia as the dependent variable.

All-cause first hospitalization and all-cause mortality were censored at 6 years of follow, December 2019, or death, whichever arrived first. Patients had a mean age of 81 years and approximately 45% were female. Among the overall study population (n = 9300), 2852 (30.7%) patients had anemia.

Overall, Wändell and colleagues found the 3 most important risk factors for anemia were male sex (odds ratio [OR], 1.97; 95% CI, 1.77–2.21), kidney dysfunction (eGFR <60 ml/min) (OR, 1.87; 95% CI, 1.69–2.08), and age ≥75 years (OR, 1.29; 95% CI, 1.13–1.48). A total of 695 (10.8%) patients without and 520 (18.2%) patients with anemia had cancer—cancer was independently linked to anemia (OR, 1.5; 95% CI, 1.3–1.17).

Other comorbidities strongly correlated with anemia included liver disease (OR, 1.64; 95% CI, 1.09–2.46; P = .017), peripheral artery disease (OR, 1.39; 95% CI, 1.18–1.65; P <.001), and diabetes (OR, 1.29; 95% CI, 1.16–1.44), as well as severe bleeding (OR, 1.80; 95% CI, 1.60–2.02).

Across the 6-year follow-up period, anemia was linked to an elevated risk of first all-cause hospitalization (adjusted hazard ratio [HR], 1.3; 95% CI, 1.2–1.4; P <.001). Individuals with HF and anemia also experienced an increased risk of death from any cause, compared with patients with HF, but without anemia (adjusted HR, 1.44; 95% CI, 1.35–1.53; P <.001).

Given these data, Wändell and colleagues pointed to the notable clinical implications for practice. As anemia is diagnosed in patients with HF, they called for the healthcare professional to treat the condition, investigate its cause, and consider cancer as a potential comorbidity.

“This is especially important given the high risk of negative outcomes in patients with HF, anemia, and cancer,” Wändell and colleagues wrote. “Thus, efforts to examine the reasons for anemia in HF patients are important.”

References

1. _{Ugarph-Morawski A, Wändell P, Benson L, et al. The association between anemia, hospitalization, and all-cause mortality in patients with heart failure managed in primary care: An analysis of the Swedish heart failure registry. Arch Gerontol Geriatr. Published online September 26, 2024. doi:10.1016/j.archger.2024.105645}
2. _{Lindberg F, Lund LH, Benson L, et al. Patient profile and outcomes associated with follow-up in specialty vs. primary care in heart failure [published correction appears in ESC Heart Fail. 2023 Jun;10(3):2143. doi: 10.1002/ehf2.14323]. ESC Heart Fail. 2022;9(2):822-833. doi:10.1002/ehf2.13848}
3. _{Chioncel O, Lainscak M, Seferovic PM, et al. Epidemiology and one-year outcomes in patients with chronic heart failure and preserved, mid-range and reduced ejection fraction: an analysis of the ESC Heart Failure Long-Term Registry. Eur J Heart Fail. 2017;19(12):1574-1585. doi:10.1002/ejhf.813}
4. _{Russo G, Rea F, Barbati G, et al. Sex-related differences in chronic heart failure: a community-based study. J Cardiovasc Med (Hagerstown). 2021;22(1):36-44. doi:10.2459/JCM.0000000000001049}